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Putting My Diagnosis Where My Mouth Is

That isn't me treating the patient, but in a few years? Photo: "House, M.D." / Fox.

Okay, so the title doesn’t make much sense.

I wanted to say something like “putting my money where my mouth is,” but that doesn’t connect with the topic of this post. Anyway, money is crawling with microbes and all kinds of awful stuff. You don’t want it anywhere near your mouth.

The Well blog on The New York Times today had a diagnosis contest under the title “Think Like a Doctor.” Since I’m going to be a doctor in a few years, I gave it a try.

The blog article was written by Lisa Sanders, M.D., who is a clinical professor of medicine at Yale University. She’s also technical advisor to the TV series “House, M.D.” and author of the book Every Patient Tells a Story.

Dr. Sanders described a patient’s history and symptoms, then challenged her readers to make the correct diagnosis. Hundreds of readers replied, including practicing physicians, nurses, and medical students. And me.

Since I’m not even in medical school yet, I don’t expect my diagnosis to be right. But it makes sense to me, and a lot of the other diagnoses that people wrote about don’t make sense to me. I have a slight edge because my Dad is a doctor: in fact, he’s a clinical professor of medicine, the same as Dr. Sanders, but not at Yale.

The Patient’s History and Symptoms

Here’s the short version of the patient’s situation, obviously focusing on what I think is important. I encourage you to read the whole article on The New York Times site.

The patient was a 76-year-old woman previously in good health except for a few minor complaints (high blood pressure and low thyroid) that were well controlled with medication. Her mother, 99, had died a few weeks earlier.

The patient initially had intestinal bleeding for which she was hospitalized. A colonoscopy found that she had blood vessel abnormalities. She was treated without surgery and recovered, but she still complained about feeling very tired.

More tests revealed a heart valve abnormality that the patient had probably had for a long time. She had an elevated white blood cell count. Although white blood cells are involved in fighting infections, an elevated white blood cell count shows only that the patient’s immune system is “on red alert,” possibly due to an infection. There can be other causes.

The patient started having mood swings and behaving bizarrely. She was alternately manic and depressed. She still complained of extreme fatigue. An MRI of the patient’s central nervous system (including the brain) was normal. She developed dark spots and infected-looking lesions on the skin of her hands and arms. She gained weight.

That’s the essence of it. And people came up with a lot of diagnoses.

Proposed Diagnoses

Many of the people who replied came up with diagnoses that I considered and then rejected.

Lyme disease was one: it’s a bacterial infection spread mostly by tick bites. It causes seemingly unrelated symptoms like the woman had. The microbe is similar to that for syphillis, a sexually-transmitted disease that several people also suggested as the cause. People who have had those infections for years can develop dementia. However, there was no indication that the woman was at risk for Lyme disease or had syphillis, so I rejected those possibilities.

Other suggestions were Cushing’s disease (caused by too much stress hormone) and Lupus Erythematosus, an “autoimmune” disease in which the patient’s immune system attacks the patient’s own body. But neither of those would have developed over a period of a few weeks. The patient had a family doctor who had treated her for years, and who would have known if she had either of those conditions. I rejected those possibilities.

Some people suggested Creutzfeldt–Jakob disease, better known as “mad cow disease” that people can contract by eating infected beef. It’s a horrible disease, but it wouldn’t have developed over a period of a few weeks. Rejected.

Some people suggested that her medications had made her sick. That’s certainly possible, since “iatrogenic illness” (illness caused by medical treatment) is the third leading cause of death in the United States, right after heart disease and cancer. But I think that her first symptom was intestinal bleeding, and that occurred before she started treatment with all the new drugs. So although iatrogenic illness is a good guess, I rejected it.

A lot of people suggested vasculitis, which is kind of a non-specific disease of blood vessel inflammation. However, from my Dad, I know that vasculitis is a “diagnosis of exclusion.” That means you diagnose someone with vasculitis when there’s obviously something wrong with them, but you’ve eliminated all the other possibilities and you can’t figure out what the problem actually is. Dr. Sanders wouldn’t have used that as a diagnostic challenge. Rejected.

My Diagnosis

I won’t find out if my diagnosis is correct until The Well blog is updated on Thursday, when Dr. Sanders has promised to reveal the answer. As I said, I don’t expect to get it right but will be thrilled if I do.

Here’s what I think. You can throw out most of the patient’s previous medical history because the onset was relatively sudden. Also, the intestinal bleeding strikes me as a symptom rather than a cause. The patient probably had the blood vessel malformations in her intestines for years. Something caused them to start bleeding.

Two facts are key:

  • The symptoms appeared within a few weeks after she had been caring for her mother, who died. We can assume that she cleaned out her mother’s house, and that the house contained items that had been there for many years undisturbed.
  • We want a diagnosis that explains fatigue, intestinal bleeding, dementia, elevated white count, and skin lesions.

My diagnosis: While cleaning out her mother’s house, the patient was exposed to black mold (Stachybotrys chartarum) and infected. Most of her symptoms resulted from the infection and from attendant mycotoxicosis from Tricothecene.

We’ll see on Thursday, April 21 if I was right.

And the Results Are In

Looks like I still have to go to medical school! :)

The correct diagnosis was Cushing’s syndrome, which I rejected because I thought that the patient’s symptoms developed too quickly and it wouldn’t explain the intestinal bleeding.

Apparently, however, the bleeding was unconnected. The Cushing’s syndrome was confirmed by a test that in a normal person should suppress blood levels of cortisol, a stress hormone. However, the test did not suppress the patient’s cortisol levels, which remained very high.

But the really exciting thing is …

Even though my diagnosis was wrong, Dr. Sanders commented on it in her blog. She said that my diagnosis was “very House-ian.” To me, that seems like a huge compliment, since she’s the medical advisor for “House, M.D.” and House is supposed to be a genius. I was excited about it, anyway. :)


Copyright 2011 by Rinth de Shadley.

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  1. eva626
    April 21, 2011 at 1:13 pm | #1

    great stuff…i would be too scared to even make an educated guess for a diagnosis like that…you’ll learn! great post

    • April 21, 2011 at 2:38 pm | #2

      Hi Eva –

      Thank you for the kind words! You noticed that I got the answer wrong, but that’s just part of learning. :)

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